VATS Pericardial Patch: Minimally Invasive Stitching

This video presents the case of a 65-year-old woman with a neuroendocrine tumor in her left lower lobe. The tumor invaded the pericardium and was staged as M1a, for which curative resection was not recommended. An initial single port VATS biopsy confirmed the pericardial invasion and obtained the histology. The tumor had a Ki 67 proliferation index of 10-15%, which put it in a moderate degree of malignancy. The tumor was expected to be indolent, and invasion into the pericardium would inevitably lead to the complication of pericardial effusion and possibly heart involvement. At the multidisciplinary meeting, it was suggested that a palliative procedure should be attempted to prevent this complication. In view of the slow rate of tumor growth, it was fully explained to the patient that the surgery would not be curative, but the redo-operative strategy was to inspect and assess the degree of pericardial invasion, and if appropriate, to proceed to lower lobectomy.

The operative access was a conventional triportal, with the camera staying in the inferior port throughout the surgery. A small hole was made in the pericardium below the limit of the tumor, to allow entry of the Enseal^TM (Johnson & Johnson, Ethicon, Cincinnati, USA), a bipolar device that is safe to use around the heart. The invaded part of the pericardium was successfully disconnected, enabling a conventional lower lobectomy.

This video shows how the author treated the large pericardial defect. Patients with large pericardial defects are at risk of heart herniation, and open thoracotomy has previously been recommended for stitching in a pericardial patch. This can now be done through a minimally invasive approach. The author demonstrates the technical aspects of safely stitching a bovine pericardial patch using a SILS^TM Stitch articulating suturing device (Medtronic/Covidien, Minneapolis, USA).